The new comparative analysis requirements and guidance is a process whereby QTLs and NQTLs can be identified and corrected before they impact plan members. Evaluating your QTLs and NQTLs by a plan is important to determine if there are any problems with parity compliance. If there are problems that are not addressed that lead to adverse medical treatment or outcomes, plan members can sue the plan sponsor under ERISA.
Based upon the operations of how plans currently operate in the marketplace, we expect most plans to need at least some changes to their plan structure and operations. In the meantime, plans continue to risk significant liabilities if those plan problems lead to poor medical outcomes of members.
QTL and NQTL Comparative Analysis is all about identifying and fixing problems before they impact plan members. Plans can also be assessed penalties of up to $100/per day per member until the plan is determined to be in compliance.
The CAA includes a specific process to follow if the DOL’s review of a plan’s analysis indicates a parity violation. After the DOL’s determination, the plan must specify what actions it will take to correct the violation and provide an additional comparative analysis within 45 days showing plan compliance. If the DOL then makes a final determination that the plan is still in violation, all plan enrollees must be notified as to the plan’s noncompliance within seven days.
QTLs & NQTLs Sponsor Risks
Evaluating QTLs (quantitative treatment limitations) and NQTLs (non-quantitative treatment limitations) is vital to determine whether there are any parity problems since QTLs and NQTLs are used to limit access to mental health and substance use disorder (MH/SUD) treatment.
For example, a visit limit for psychotherapy may hinder a patient’s access to necessary care, while the need for preauthorization before treatment could lead to delays and cause patients to eventually drop out of care. The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that group health plans and health insurance issuers provide MH/SUD benefits in parity with medical/surgical (med/surg) benefits. In essence, QTLs and NQTLs applied to MH/SUD benefits cannot be more restrictive than those applied to med/surg benefits.
The Mental Health Parity and Addiction Equity Act (MHPAEA) mandates that health insurance providers and group health plans ensure equal benefits for mental health/substance use disorder (MH/SUD) as they do for medical and surgical treatment. Essentially, the quantitative treatment limitations and non-quantitative treatment limitations imposed on MH/SUD benefits should not be more stringent than those set for medical and surgical benefits.
If a plan’s QTLs or NQTLs are found to be more restrictive for MH/SUD benefits than for med/surg benefits, this could be considered a violation of MHPAEA. Plan members adversely affected by such a parity infringement have the right under the Employee Retirement Income Security Act (ERISA) to sue the plan sponsors.
ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. Under ERISA, plan participants and beneficiaries have the right to sue plan fiduciaries for breaches of fiduciary duty.
In the context of parity, a plan fiduciary could be held liable for a breach of fiduciary duty if they failed to ensure that the plan’s QTLs and NQTLs were in compliance with MHPAEA. If a plan member is able to prove that they were harmed by a parity violation, they may be entitled to damages, including
- Medical expenses
- Lost wages
- Emotional distress
- Punitive damages
In addition to damages, a court may also order the plan to provide the plan member with the benefits they were wrongfully denied. Therefore, it is important for plan sponsors to carefully evaluate their QTLs and NQTLs to ensure that they are in compliance with MHPAEA.
MHPAEA Compliance Risks Services
Our Mental Health Parity Compliance Risks services provide the best options for NQTL and QTL compliance by:
- Conducting comprehensive MHPAEA compliance audits that identify and assess any potential parity violations.
- Providing expert guidance on the development and implementation of MHPAEA-compliant QTLs and NQTLs.
- Monitoring plan compliance with MHPAEA on an ongoing basis.
Our team of experienced MHPAEA compliance professionals can help you:
- Understand the complex MHPAEA requirements.
- Identify and address any potential MHPAEA violations.
- Develop and implement MHPAEA-compliant QTLs and NQTLs.
- Reduce your risk of MHPAEA penalties and lawsuits.
- Protect the rights of your plan members.
Financial Penalties for Non-compliance
Plans can also be assessed penalties of up to $100/per day per member until the plan is determined to be in compliance.
The CAA includes a specific process to follow if the DOL’s review of a plan’s analysis indicates a parity violation. After the DOL’s determination, the plan must specify what actions it will take to correct the violation and provide an additional comparative analysis within 45 days showing plan compliance.
If the DOL then makes a final determination that the plan is still in violation, all plan enrollees must be notified as to the plan’s noncompliance within seven days.